COVID Follow-Up Questionnaire

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This form is used to collection additional information on individuals who may have symptoms, exposure, or recent COVID test. Your response will be sent to Graham Health Center.

Email *

What is your role at Oakland University? *

Do you live on OU Campus? If Yes, Please identify building you live in. *

First Name *

Last Name *

Phone Number *

I experiencing the following symptoms: *

I am NOT having any symptoms

cough

fever (greater then 100.4)

sore throat

new, unexplained congestion

muscle aches

loss of taste or smell

headache

diarrhea

nausea or vomiting

Required

What date did the above symptoms begin?

YYYY

Have you tested positive for COVID-19 within the last 10 days? *

Yes

If you answered YES to the previous questions, please enter the date of the test.

YYYY

Have you had Close Contact to someone who recently tested positive for COVID-19? *close contact is defined as being less than 6 feet from a person for 15 minutes or greater* *

Yes

Maybe

If you answered YES to the previous questions, please enter the last date of exposure.

YYYY

Did you receive the Covid-19 Vaccine? *

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